Just when you thought you would have the annual “spring break” from the Medicare Advantage (MA) retrospective risk adjustment chart reviews, The Centers for Medicare & Medicaid Services (CMS) releases a memo extending the deadline for Risk Adjustment Payment System (RAPS) submissions to May 3, 2018. For those plans and communities impacted by extreme weather in 2017, this is a lifeline.

For those unaffected, this is an opportunity like you used to get when your teachers gave you an extra weekend to finish a term paper. If you were like me, you still waited until Sunday night at 9pm to finish the paper. Back then, millions of dollars weren’t on the line, and I wasn’t accountable for putting a competitive, comprehensive portfolio of MA products on the market – I miss the old days.

So now that you have this extension, what are you going to do? I’ve listened to what our colleagues are saying, and there are mixed opinions on whether or not to take action.

The list of barriers heard from colleagues:

  • Requesting, retrieving, and reviewing more records isn’t in the budget, plain and simple, and the ROI just isn’t there.
  • We don’t have the internal resources to review more records for MA, especially if we shift staff from MA over to ACA chart reviews before submissions are due. And we share staff with HEDIS, which puts us in an even bigger bind.
  • Our vendor barely had capacity to review more records with the original deadline, because they received an influx of requests from all its clients. Why pay to retrieve them if they can’t be reviewed?
  • Someone needs to do QA on these additional records, and you don’t have capacity, so why risk exposure to a Risk Adjustment Data Validation (RADV) audit?
  • Your provider network is already annoyed, and you really need them to stay engaged while you prepare for HEDIS abstraction season and/or finish your ACA reviews.
  • My team is going on vacation. Yes, that is a real thing…

If you do decide to retrieve and review more records, below are a few things to consider.

4 things to consider when retrieving and reviewing records:

1. Stick to Your Priorities – Go back to your analytics. Identify members that represent the greatest opportunity and start with those. If you didn’t get records from your first round that you know will have a significant impact on your Risk Adjustment Factor (RAF) score, ask again. Work with your vendor to re-prioritize your chase list and be intentional about your priorities and why. They should have the data to help you make an informed decision, so let them have a seat at the strategic table. If you need help with the analytics, get in touch with me, and I’ll point you in the right direction dweinrieb@swhealth.com.

2. Make It Easy on Your Providers – You are in prime chart retrieval season, and if you have both MA and ACA products, your providers are as exhausted as you are. The CMS extension bleeds into HEDIS chart abstraction season and into the final push for ACA. Get with your HEDIS team, share your chase list with theirs, and work together to formulate retrieval efforts that are both cost-effective and provider-friendly. Keep in mind, you are not the only health plan in town. These providers are bombarded with requests from everyone. While you’re at it, ask your providers to reconcile their directory data with you. We can all do better than 50% accuracy!

3. Be Efficient – It’s a real possibility that a single provider could receive three or more requests to retrieve and review records from your health plan: HEDIS, MRA, and ACA. Work together to bundle these efforts as best you can so that you don’t have to pay three times for records on the same member and in the same provider system. Not only will you find overlap with the providers/locations, you might also find overlap with the members themselves. If you already had retrieval dates set for ACA, pickup MA records in that office whenever possible – just make sure to be compliant.

4. Most importantly, Eliminate These Barriers and Plan Ahead! – Year after year, I hear the same challenges, regardless of grace periods extended to us by CMS. The common themes of resource constraints and competing priorities; people, time, and money are perpetual problems. I’m not just hearing it from the health plans; industry vendors also live this torture annually. Recently, I received 5 separate calls from health plan and services vendor colleagues asking me if I had an extra 20-30 resources to support reviewing records during the last weeks of January sweeps (and now through May). When I worked for health plans, we asked our vendors the same thing, every year. We weren’t close enough to hitting our Risk Adjustment (RA) budget or RAF score, so we needed to go to the next tier of “prioritized” records. Quick math leads me to think these 5 colleagues were in danger of leaving about $100M on the table for Medicare Advantage RA.

The Shearwater Solution:

Solving for these barriers has been my top priority since joining Shearwater Health. Our solutions make a difference. Our clients save an average of 40%. And our quality outcomes – completeness and accuracy – are consistently at 98%. Our model adjusts and accommodates for surges in medical record reviews as well as the seasonality of the RA and HEDIS programs. Our clients never have to worry about capacity or cost because we design and construct your clinical team based on historic retrieval and review patterns, your work plans, and your strategies, and we do it all within your existing technology platforms.

The foundation of Shearwater’s clinical model is cross-trained Nurse Coders, certified in Risk Adjustment Coding, experienced in HEDIS abstraction, and versed in the regulatory requirements from both CMS and NCQA. Orchestrating these cross-departmental programs that are the lifeblood of your government-sponsored programs has never been more critical. Position yourself for success and avoid being in the same situation year after year. Engage Shearwater Health to build clinical infrastructure that will eliminate these common barriers. Contact us for strategic consulting and information on how Shearwater can deliver immediate value to your company.

Daniel Weinrieb 
EVP, Government Programs